Donor/Referral Process: An Overview

1. Donor/Referral Process:An Overview Laura Stacie & Heather Lindner Organ Procurement Coordinators

2. Organ Procurement Coordinator • 8 Coordinators for UW-OPO • Staffed 24/7 • Job Description • Take new referrals/Check on existing referrals • Work-up cases/On-going family support • Take outside organ offers

3. Referral Phase – Recovery Phase Referral Phase Consent Phase Serology Phase Management Phase Allocation Phase Recovery Phase

4. How do I make a referral? 1-866-UWHC-OPO (1-866-894-2676)

5. Clinical Triggers A mechanically ventilated patient with a severe neurologic insult or injury • For whom a physician is evaluating for brain death OR • A patient with a Glasgow Coma Scale (GCS) < 5 OR • A plan to discuss withdrawal of life-sustaining therapies

6. What information does the OPOneed on the initial referral?

7. Have patient’s chart available! Name Age Ventilator status Cause of death Coroner’s Case (County of accident/event) Past Medical/Social History Height/Weight Current pressors, vital signs, neuro status, labs Family status/ Plan of Care

8. Initial Screening Information Kidneys: BUN, Cr, UA, C&S, UOP, Age < 75 Liver: LFT’s, Age <70 Pancreas: Amylase, Lipase, Age <55 Heart: EKG, Echo, Cardiac Cath Lungs: O2 Challenge, Bronch, CXR, Sputum Gram Stain, Lung Measurements (Information needed to determine patient elligibility. May rule a patient out on initial referral.)

9. Current Criteria for Organ Donation • Pt declared brain dead –or— • Pts with severe neuro injury and family and MD are withdrawing vent support • Up to age 75 • No active malignancy (except CNS tumors) Remember….donors are evaluated on case by case basis.

10. Following Referrals If withdrawal or brain death is not imminent, communication plan made with RN Usually 1-2 days between phone calls. On imminent patients, checks made more frequently If RN is busy, OPC will call back If pt improves, referral closed

11. Information the OPC Needs to Know Current status of patient Events happening during the course of the day Family plans

12. If brain death is suspected or the family has decided to WD support we will move on to the next phase.

13. Diagnosing and Declaring Brain Death • Known cause of irreversible brain injury • Absence of: • CNS depressants, including alcohol or sedatives • Neuromuscular blockade • Severe metabolic, hemodynamic, or endocrine derangement • Core Temperature > 32 degrees C (90 degrees F) • Clinical exam • Confirmatory Tests

14. Elements of brain death declaration Date Time Complete documentation of clinical exam and apnea test Confirmatory Test results-if performed Physician Signature Note: We can provide a template if needed.

16. Futility Note • Needs to state by MD that they have spoken with the family and care is futile. The decision has been made to withdraw care by the family. • Date, time, and signature are also needed. • A sample futility note can be provided.

17. Consent Phase Team Huddle Understanding of grave prognosis/brain death Dual advocacy

19. Serology Phase Eligible donor + verbal interest from family = start serologies. Serology instruction form Please fax back to coordinator once filled out. Coordinator sets up transportation for serologies.

20. Serology Phase BLOOD • RN ER • Courier picks up blood at ER and drives to Madison. • OPO Coordinator alerts core lab and tissue typing of blood arrival and they prep kits for testing. • Serologies take about 4 hours to complete.

21. Serology Testing HBSAg- Hepatitis B Surface Antigen Anti- HBC- Hepatitis B core Anti- HCV- Hepatitis C Virus HIV 1 and 2- Human Immunodeficiency Virus HTLV 1 and 2- Human T-cell leukemia/lymphoma virus RPR- Rapid Plasma Reagin test- Tests for syphilis CMV- Cytomegalovirus (many are positive) EBV- Epstein Barr Virus

22. Management Phase Medical Social History Family Support Placement of appropriate lines Monitoring lab values Monitor vital signs/UOP/CVP/gtt use Organ Evaluation

23. Medical/Social History and Family Support • Medical/Social History completed prior to allocation/recovery • Complete with person who knows the pt best • May be done with multiple people • OPO always available for family support

24. Information Needed to Evaluate Donor • FACE sheet/Demo Sheet (urgent information) • Copy of blood type (urgent information) • H&P • Chest x-rays, CT scans, EKG • Dictated consults • Daily Nursing Flow sheets with vitals and I&O’s • ER flow sheets • Meds from last 24 hours • Blood Products administered • Consent form (2 if DCD) • Labs since admission • Brain Death clinical exam/apnea test results or DCD futility note • Please send ASAP (No need to send all at once)

25. Placement of Lines • An arterial line and a central line needed • Many times CVP’s will need to be measured • Lines placed by the MD’s, residents, etc • Needed for most cases

26. Lab Values/Blood Cultures • Stat labs • ABO/RH Typing and Type and Screen (IMPORTANT TO OBTAIN ASAP with Demo/FACE Sheet!!!) • Blood Cultures x 2 (different sites), Sputum Culture with Gram Stain, Urine Culture and Sensitivity, UA • CBC with diff., ABG, Chem 10, LFT’s, Coags, Amylase, Lipase, Cardiac Enzymes, HgbA1c

27. Lab Values (cont.) • Every 6-8 hours re-check • CBC, Chem 10, LFT’s, Coags, Amylase, lipase, cardiac enzymes • Standing orders are given to replace electrolytes. • Changes will be made by coordinator if needed. • If brain dead patient--OPO can give orders • If DCD patient--OPO can give suggestions.

28. V/S, UOP, CVP, Drips… • Measured every hour • Use orders/recommendations given by the coordinator. • Rule of 100’s • SBP above 100 • PaO2 above 100 • UOP at 100ml/hr

29. Organ Evaluation Echocardiogram Bronchoscopy Multiple chest x-rays Cardiac Cath Abdominal CT O2 Challenges Multiple ABG’s

30. Allocation Phase Once all of this information is received, entered into our databases, tests are complete, and serologies are done, we can begin allocation ALLOCATION: The process used to offer out organs according to the UNOS list of recipients that need an organ transplant.

31. Organ Allocation • Information is entered in database and lists are run • Lists show recipients that are matches to the donor • Based upon: • Length of wait time • Antibodies • Status 1A (Very sick pt) • 0 mismatches (PERFECT MATCH) • Local, regional, and national unless there is a Status 1 recipient listed.

32. Organ Allocation Each organ allocated separately. Each transplant center has 1 hour to acknowledge offer Each transplant center has 1 hour from time of information to make decision Can be a very long and tedious process There are many, many phone calls during this period Additional tests may be requested during this time. Lots of communication with transplant physicians to determine if recipient is a good fit for this donor

33. UNet Screen Shot

34. Recipients • Once a recipient is selected for an organ, a transplant coordinator calls the patient into the hospital • Recipients always are available by cell phone or pager • They have 1 hour to respond and make decision • Need to get to hospital and get ready • Labs, x-rays, prepped for OR

35. TIME TO GO!!! • Once Allocation is complete it is time to get our team ready to go! • Usually a Surgical Recovery Coordinator, a recovery physican, and an assistant will go on case • An OPC will go on every DCD case • The coordinator will arrange transportation (flight) to airport and then transportation from airport to hospital

36. Recovery Phase: Surgical Recovery of Organs All organs except kidneys need to be allocated to specific recipient prior to recovery All infectious disease tests must be completed and confirmed Some teams will need time to fly in from their location (Could be multiple teams) UWHC transplant team must be in the OR before taking the pt to the OR

38. Brain Death Recovery Process • Patient is maintained on ventilator throughout organ recovery • Organs are dissected in situ • 3-4 hour surgery • Heart, lungs, liver, kidneys, pancreas and intestines can be recovered

39. Donation After Cardiac Death • Withdrawal of life support in OR or ICU • Cardiac death occurs • Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician • Rapid recovery with organs procured en bloc • 1-2 hour surgery • Lungs, liver, kidneys and pancreas can be recovered

41. Preservation Times Heart: 4-6 hours Lungs: 4-6 hours Liver: 12 hours Pancreas: 12-18 hours Kidneys: up to 72 hours Small Intestines: 4-6 hours+ Tissues: up to 3-4 years Corneas: up to 7 days

43. What happens after a case? The organs are taken back to the transplant centers and either cold stored or transplanted right away. Liver/Pancreas- Recipient waiting and transplant happens very quickly. Heart/Lungs- Recipient already in OR when organs arrive and transplant happens immediately. (Lots of communication needed!!) Kidneys- Can be transplanted soon after arrival or placed on kidney pump for up to 24 hours. Pumping helps to preserve and work more efficiently.

45. What happens after a case?? (cont.) • If organs are not staying at our transplant center the surgical recovery coordinator packages the organs and ships them to the transplant centers accepting the organs. • Other things done after a case… • Biopsies • Lymph Node/Spleen typing • More dissection/cleaning up the organs

46. After Action Reviews • About 1 week after the case happened • OPO Staff • Coordinators • Hospital Service Specialist • Surgical Recovery Staff • Hospital Staff • RN’s working w/ donor • ICU Manager • Hosp. Liason • OR staff • Chaplains • Safe environment to discuss what went well and things that need improvement!!

47. Through donation ... ...lives are changed forever

48. QUESTIONS????